Healthcare Provider Details

I. General information

NPI: 1477679736
Provider Name (Legal Business Name): DOUGLAS WILLIAM BYRD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DR SUITE P-231
JACKSON MS
39216-4913
US

IV. Provider business mailing address

1855 LAKELAND DR SUITE P-231
JACKSON MS
39216-4913
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-4696
  • Fax: 601-366-6574
Mailing address:
  • Phone: 601-366-4696
  • Fax: 601-366-6574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15999
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: